a)Cramping pain in both thighsb)Pain in the calf musclesc)Tenderness on plantar flexiond)Pallor of the leg on elevationWhich of the following is true regarding self breast examination?

a)A high proportion of breast masses are detected by self breast examination.b)It is recommended unanimously by organizations making screening recommendations.c)The undue fear caused by finding a mass justifies omitting instruction in self breast examination.d)It has been shown to reduce mortality from breast cancer.

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a)Cramping pain in both thighsb)Pain in the calf musclesc)Tenderness on plantar flexiond)Pallor of the leg on elevationWhich of the following is true regarding self breast examination?

a)A high proportion of breast masses are detected by self breast examination.b)It is recommended unanimously by organizations making screening recommendations.c)The undue fear caused by finding a mass justifies omitting instruction in self breast examination.d)It has been shown to reduce mortality from breast cancer.

A nurse recognizes that a common complication of vascular surgery may manifest as which assessment finding?

a)Cramping pain in both thighsb)Pain in the calf musclesc)Tenderness on plantar flexiond)Pallor of the leg on elevation

Pain in the calf muscles

Which of the following is true regarding self breast examination?

a)A high proportion of breast masses are detected by self breast examination.b)It is recommended unanimously by organizations making screening recommendations.c)The undue fear caused by finding a mass justifies omitting instruction in self breast examination.d)It has been shown to reduce mortality from breast cancer.

A high proportion of breast masses are detected by self breast examination.

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The nurse is assessing an 82-year-old elderly man who lives alone and was brought to the clinic by his grandson. His hair is messy, he has very bad body odor, and his clothes are very dirty. What do these signs most likely indicate to the nurse?

a)The patient has decreased functional abilityb)The patient is lazy and appearance no longer matters to himc)The patient is being neglectedd)This patient needs to live in a nursing home

The patient has decreased functional ability

The nurse would auscultate for voice sounds during which part of the comprehensive examination?

a)Abdomenb)Neckc)Posterior chestd)Head and face

Posterior chest

During palpation of the male genitalia, which of the following is an expected finding?

a)Beading of the vas deferensb)Palpable spermatic cordc)Painless testicular nodulesd)Tortuous veins in the scrotum

Palpable spermatic cord

When examining a client's thyroid gland, the nurse ensures that which equipment is readily available?

a)Cup of waterb)Penlightc)Centimeter-scale rulerd)Tongue depressor

Cup of water

The results of a client's ECG and D-dimer levels suggest a pulmonary embolism. Which of the following history and examination findings would the nurse expect in light of this diagnosis?

a)Fine crackles to bases on auscultationb)Sudden onset of dyspneac)History of heart failured)Relief of dyspnea with guided deep breathing

Sudden onset of dyspnea

A patient is 20 weeks pregnant and has melasma. What information can the nurse give the patient about melasma, when educating her about the effects of pregnancy?

a)Melasma is always permanentb)Melasma generally resolves postpartumc)Melasma can be treated with Betadine ointmentd)Melasma should be treated with antibiotics

Melasma generally resolves postpartum

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?

a)Pupils dilate in response to a light shone in the eyesb)Light reflection appears at different spots on both eyesc)Eyes do not converge to focus on a shining lightd)Nonreaction of the opposite pupil to light

Nonreaction of the opposite pupil to light

A patient has a nursing diagnosis of ineffective coping related to repeat episodes of diarrhea and financial stressors. Which of the following is not an appropriate intervention for this nursing diagnosis?

a)Identify additional resources availableb)Gradually increase activity as toleratedc)Accurately assess stressors and effectiveness of coping methodsd)Allow time for the patient to express feelings

Gradually increase activity as tolerated

A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client?

The nurse is inspecting the cervix of a client who has two children. The nurse would expect the cervical os to appear as which of the following?

a)Slit-likeb)Roundc)Transversed)Stellate

Slit-like

When interviewing, the nurse should logically move from specific to open-ended questions.

a)Trueb)False

False

The nurse is preparing to conduct a health assessment with a patient. What will be the nurse's initial role when caring for this patient?

a)Identifying interventionsb)Collecting datac)Teachingd)Planning care

Collecting data

A child presents to the health care facility with new onset of a foul smelling, purulent drainage from the right nare. The mother states no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?

a)Inspect the nostrils with an otoscopeb)Assess for allergies to antibioticc)Reassure the mother that this is common in childrend)Have the child blow the nose to assess drainage

Inspect the nostrils with an otoscope

From data collected during the health assessment, the nurse determines that a patient would benefit from smoking cessation information. What would be the best approach for the nurse to take when teaching smoking cessation to this patient?

Discuss with the patient if smoking cessation is a goal the patient may have.

A nurse suspects that a client may have a pericardial friction rub. To ensure that the nurse hears this, the nurse would place the client in which position?

a)Flat, left lateralb)Leaning forward while in a sitting positionc)Supine with head of bed elevated 30 degreesd)Sitting upright in a straight back chair

Leaning forward while in a sitting position

The nurse is examining a 77-year-old man. During the physical assessment, the patient appears to be getting fatigued. What can the nurse do to help the patient finish the assessment?

a)Omit testsb)Halt the assessment, and finish when the patient has enough strengthc)Divide the assessment into portionsd)Rush through each activity to finish more quickly

Divide the assessment into portions

During the first assessment of the client, the nurse assesses the blood pressure in both arms. Which of the following findings is an acceptable variation?

a)118/78 mm Hg in the right arm and 130/84 mm Hg in the left armb)140/90 mm Hg in the right arm and 150/96 mm Hg in the left armc)140/95 mm Hg in the right arm and 130/85 mm Hg in the left armd)118/78 mm Hg in the right arm and 122/80 mm Hg in the left arm

118/78 mm Hg in the right arm and 122/80 mm Hg in the left arm

When auscultating a client's heart sounds the nurse detects a murmur that is initially loud and then gets softer. The nurse determines the pattern of this murmur to be which of the following?

a)Crescendob)Crescendo-decrescendoc)Plateaud)Decrescendo

Crescendo-decrescendo

A client is found to have leukoplakia, and the nurse is teaching the client about measures to reduce the client's risk. Which of the following would the nurse include in the teaching?

a)“Make sure to get lots of vitamin from the sun.” b)“Increase your intake of foods high in iron and zinc.” c)“Avoid substances that could be irritating to your mouth.” d)“Use a humidifier to increase the moisture in the environment.”

“Avoid substances that could be irritating to your mouth.”

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

What should the nurse do before conducting a physical examination of a patient?

An 18-year-old woman is about to undergo a physical assessment conducted by a nurse practitioner at the gynecology clinic. The nurse is preparing the room for a complete head-to-toe examination, along with a genitalia and rectal assessment and screening through the Papanicolaou test. What should the nurse do next before proceeding?

Ask for the patient's permission to perform the assessment

A 27-year-old farm worker presents at the ED after falling out of a hay loft. The patient states that he fell approximately 4 hours ago and did not lose consciousness. He adds that he is experiencing only a mild headache. When asked why he came to the ED, the patient states that he had a clear discharge from the right ear ever since the accident. What should this finding indicate to the nurse?

Possible basilar skull fracture

When documenting assessment of the nervous system, a nurse should keep in mind what important principle?

Describe the response

The nurse documents a 2+ radial pulse. What assessment data indicated this result?

brisk, expected (normal) pulse

A nurse obtains an order to measure a client's leg length. How should a nurse correctly implement this order?

Measure from the anterior superior iliac spine to the medial malleolus

The nurse is going to assess a patient's ankle–brachial index. Which equipment will the nurse use for this assessment?

• Doppler device• Blood pressure cuff

Which of the following accompanies decreased ovarian function?

Decreased vaginal secretions

Mrs. T. comes for her regular visit to the clinic. Her regular provider is on vacation, but the client did not want to wait. The nurse has heard about this client many times from colleagues and is aware that she is very talkative. Which of the following is a helpful technique to improve the quality of the interview for both provider and client?

Briefly summarize what the client says in the first 5 minutes and then try to have her focus on one aspect of what she discussed.

The nurse is determining the number of annual influenza inoculations that will need to be provided to a group of community members. Which members would benefit from receiving this vaccination?

A registered nurse is working with an APRN at a local walk-in clinic. The APRN needs to perform an objective assessment of a patient's left ear. What equipment would the RN make sure is in the room?

• High-pitched tuning fork• Otoscope

A 60-year-old man is having his skin assessed. The patient tells the nurse he has been a heavy smoker for the last 40 years. He has clubbing of the fingernails. What does this finding tell the nurse?

The patient has chronic hypoxia

Due to a change in the client's status, a nurse is now assessing a client's temperature by the axillary route. Previously, the client had an oral temperature of 98.4oF. Which finding would the nurse interpret as within the range of the client's previous temperature?

97.4oF

After teaching a group of young women about breast self-examination, the nurse determines that the teaching was successful when the women state that they will palpate their breasts using which pattern?

Vertical strip

A nurse assesses a client for pupillary response of the eyes finds unilateral dilated pupils that are unresponsive to light or accommodation. The nurse recognizes that which cranial nerve is responsible for the damage of pupillary response?

III

When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate information?

Dorsal hand surface

The terms “generalized,” “exposed surfaces,” “upper arm,” and “skin folds” are used to describe which major characteristic of skin lesions?

Distribution

The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal?

4 mm

Francis is a middle-aged man who noted right sided lower abdominal pain after straining with yardwork. Which of the following findings would make a hernia a more likely diagnosis?

Absence of symmetry of the inguinal areas with straining

The nurse is assessing an elderly patient. The patient knows her name but does not know where she is and what day it is. The patient is also unfamiliar with her situation. How would the nurse state these findings in the chart?

Alert and oriented times 1

When assessing an elderly patient's ability to return to the community following discharge, it is important for the nurse to measure the patient's abilities in relation to instrumental activities of daily living. All of the following are considered activities of daily living except?

Family assistance

When can the general inspection be started?

As soon as the examiner first sees the client

A 29-year-old woman with a longstanding diagnosis of genital herpes has presented to the clinic because of a recent “flare-up.” What should the nurse expect during inspection of this recurrence of herpes?

A local patch of small, painful lesions on the client's vulva

A nurse recognizes that the second heart sound, S2, is produced by which cardiac action?

Closure of the semilunar valves

The nurse instructs the patient to raise his arm out to the side and overhead. The nurse is asking the patient to adduct his arm.

False

A group of students are reviewing the structure and function of the skin in preparation for a test on the material. The students demonstrated understanding when they identify which layer as the outermost layer of the epidermis?

Stratum corneum

A patient has been assigned a nursing diagnosis of fatigue related to anemia as evidenced by pale skin, statements of tiredness, and low hematocrit and hemoglobin values. What would be an appropriate nursing intervention for this patient?

Collaborate with the physician to treat anemia

Upon inspection of a client's oral cavity, a nurse observes a bifid uvula. What should the nurse recognize about this finding?

This is often a normal finding in the Native American population

After a physical examination of the peripheral and vascular systems, the nurse determines that a patient is at risk for the development of venous disease. What teaching would be appropriate for this patient? (Select all that apply.)

A nurse is examining a client's neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes?

2

When beginning the collection of the client data base, which of the following would be most important for the nurse to do?

Establish a trusting relationship

A client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, and a deep, wet cough. A nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data?

Ineffective Airway Clearance

While the nurse performs patient assessment,assistive personel often observe changes when obtaining vital signs or assisting patients with ADLs. When discussing care for a patient with back pain, the nurse should particularly alert the assitant to watch for

Bowel/bladder incontinence

A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75mmHg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?

120/55mmHg

When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?

Uvula and soft palate rising bilaterally

A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, “I can never seem to get warm, no matter what the thermostat is set at.” How should the nurse proceed with assessment?

Assess the woman for hypothyroidism.

When auscultating a patient's heart, the nurse hears both S3 and S4. What is this known as?

Summation gallop

Sometimes it is necessary to use a tuning fork when performing a physical assessment. What would be one instance where a tuning fork would be used?

To determine vibration sense in the neuromuscular system

The nurse has completed the inspection of a patient's abdomen during the physical examination. Which technique will the nurse use next during this examination?

Auscultation

The nurse is preparing to assess a female client's activities related to health promotion and maintenance. Which question would provide the most objective and thorough data?

"Could you describe how you perform self-breast exams?"

Which of the following would be most important for the nurse to remember when auscultating the thorax?

Listen at each site for at least one complete respiratory cycle

The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for evaluation of fatigue, weight gain, and hair loss. The previous clinician had a strong suspicion that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client with hypothyroidism?

Dry and rough

A nurse is inspecting a client's eyelids and eyelashes. Which of the findings would the nurse document as abnormal?

Drooping of the upper lid

A nurse receives an order to perform a compression test to assess the competence of the valves in a client's varicose veins. Which action by the nurse demonstrates the correct way to perform this test?

Firmly compress the lower portion of the varicose vein.

The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate?

“Before I get ready to examine the painful area, I will let you know in plenty of time.”

The nurse is documenting normal findings after assessing the patient's skin. All of the following are examples of normal findings except?

Mucous membranes are pale and moist

Which technique should the nurse use to examine the sinuses of a client with a sinus infection?

Press up on the brow on each side of the nose to palpate the frontal sinus.

A client is brought to the health care facility with a sudden loss of movement on the right side of the body. Upon assessment, the nurse finds that the client has a slight flicker of contraction in the muscles on the right side. What should the nurse document as the muscle strength rating?

1

When assessing the skin, hair, and nails of the older adult, the nurse needs to know the normal effects of aging on these structures. Which of the following are normal effects of aging on the integumentary system?

• Nails become thick and brittle with slow growth• The epidermis thins• Wound healing slows as a result of decreased mitotic activity

While assessing a patient, the nurse notes that the patient is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process?

emotional

Which lung sound possesses the following characteristics? Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration.

Bronchial

The exact cause of BPH is unknown, but the condition is believed to be associated with what?

Age-related hormonal changes

Many older adults are edentulous, which can cause overclosure of the mouth. What can this lead to?

Angular cheilitis

A client is concerned about a dark skin lesion on her anterolateral abdomen. The lesion has not changed, nor is there any discharge or bleeding. On examination there is a medium brown circular lesion on the anterolateral wall of the abdomen. It is soft, has regular borders, is evenly pigmented, and is about 7 mm in diameter. What is this lesion?

Supernumerary nipple

Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?

Unequal expansion of the chest

An avid swimmer presents with ear pain. Her history includes pain and drainage from the left ear. On examination, she has pain when the ear, including the tragus, is manipulated. The canal is narrowed and erythematous with some white debris in the canal. The rest of the examination is normal. What diagnosis would be most appropriate for this client?

External otitis

The nurse is assessing a patient complaining of swelling in his neck. While palpating his neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation?

This could be a sign of cancer

In the older adult, which changes in the peripheral vascular system can increase blood pressure?

Arterial walls are less elastic and stiffen

Which of the following would the nurse most likely document when noting a small opening in the skin surrounding the anal opening?

Anorectal fistula

A nurse recognizes that it is best to begin the objective data collection with which procedure?

Measure the client's vital signs, height, and weight

When obtaining an oral temperature on a client, the nurse inserts the thermometer:

Deep in the posterior sublingual pocket

Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern?

"Do you have family who visit you regularly?"

The nurse is assessing a client's ability to shrug her shoulders against resistance. The nurse is assessing which cranial nerve?

XI

A nurse recognizes that the normal breath sounds that are auscultated over the peripheral lung fields are what type of sound?

Vesicular

A 68-year-old retired truck driver comes to the office for evaluation of swelling in his legs. He is a smoker and has been taking medications to control his hypertension for the past 25 years. The nurse is concerned about the client's risk for peripheral vascular disease. Which of the following tests is appropriate to order to initially evaluate for this condition?

Ankle-brachial index (ABI)

A nurse is presenting a class to a local community about vision and eye health. As part of the presentation the nurse explains how visual perception occurs. Which of the following would the nurse include in the explanation?

Involves light rays striking the retina

The nurse is gathering equipment to perform a skin assessment on an elderly patient. What type of equipment will be needed?

An elderly Vietnamese patient is having his skin assessed. The nurse notes multiple bruises and abrasions on his legs. What practice by Southeast Asian people could this be the result of?

Coining

A client is admitted to a health care facility with new onset of abdominal pain, fatigue, and low back pain. The client relates a 10 year history of high blood pressure. When auscultating the client's abdomen for bowel sounds, what other assessment should the nurse perform at this time?

A client visits the health care facility with reports of mild hearing loss. The nurse prepares to perform which test to compare bone and air conduction?

Rinne

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. Client states he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?

Risk for Injury

After teaching a group of students about the anal canal, the instructor determines that the teaching was successful when the students state which of the following?

The internal sphincter is under involuntary control.

A client sustains an injury to the brainstem. What is the most important assessment parameter that the nurse should perform for this client?

Depth of respirations

Which of the following acute abdominal symptoms could be life threatening?

Abdominal pain

The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal?

4 mm

Body temperature varies with all of the following except?

Diet

Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?

Modes of transportation are the leading cause

The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The nurse would document this as which of the following?

2+

Which of the following would the nurse implement in response to a collaborative problem?

Taking blood glucose twice daily

In the female patient, the tube of muscular tissue that extends from the vaginal introitus to the uterus is called what?

Vagina

After teaching a group of students about geriatric syndromes, the instructor determines that the teaching was successful when the students identify which of the following as an example?

Confusion

A client presents to the health care clinic with reports of inability to concentrate at work and daily frontal headaches for the past two weeks. What additional information should the nurse ask this client?

"Are you experiencing sinus pressure and congestion?'

An elderly female client is accompanied by her daughter on a visit to the health care facility. The nurse observes that the client is doing quite well, except for the use of a hearing aid. How can the nurse best facilitate the interview process with this client?

Speak slowly and clearly, using straightforward language

The nurse is performing a physical examination and is using a stethoscope to listen to lung sounds. When using the diaphragm, the nurse would expect to hear lower-pitched sounds.

False

A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate understanding of the waveforms when they identify which component as indicating ventricular repolarization?

T wave

The nurse is doing a neurologic screening examination. The nurse should include some aspect of which areas? Select all that apply.

A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis?

Exophthalmos

A nurse performs light palpation of the abdomen and feels a prominent, non-tender, pulsating mass above the umbilicus that measures approximately six (6) centimeters. What is an appropriate action by the nurse?

Stop the palpation & notify the health care provider

After explaining the skills used to gather subjective and objective data, the instructor determines that additional teaching is needed when the students identify which of the following as a skill necessary for collecting subjective data?

Inspection

A nurse assesses the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute?

45-60

The nurse is having difficulty auscultating a patient's bowel sounds during a physical examination of the abdomen. What can the nurse do to improve hearing the patient's sounds of this body area?

Reduce all environmental noise.

An older adult client presents with cramping leg pain when walking, which is relieved by rest; cool pale feet; capillary refill in the toes of 4 to 6 seconds; negative Homans' sign bilaterally; no edema; and inability to palpate dorsalis pedis and posterior tibial pulses bilaterally. Which of the following would the nurse suspect?

Arterial insufficiency

The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse determines correct technique when the new graduate is observed pressing deeply at which anatomic location?

Right lower quadrant

What is an appropriate action by a nurse when providing care for an 18 year old with respiratory problems caused by excessive smoking?

Suggest methods and provide resources to assist with smoking cessation

Which of the following are the four major axillary node groups?

Pectoral, subscapular, lateral, central

A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?

Parkinson's disease

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII?

Head and face

As part of the nursing profession, nurses function as patient advocates. What is one way in which a nurse advocates for a patient?

Identifying the side effects of treatment

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test the near visual acuity using a Jaeger reading card?

Instruct the client hold the chart 14 inches from the eyes

The school nurse assesses unequal shoulder and scapula height in an adolescent. Which of the following would the nurse assess next?

Spinal column

A client tells a nurse that she has been experiencing intermittent episodes of numbness, tingling, pain, and burning in the fingertips, especially after being cold. What is an appropriate question for the nurse to ask the client to further assess this occurrence?

"Do you notice your fingers changing colors?"

The nurse is planning care for a patient recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development?

Immobility

The nurse is preparing to perform the Rinne test on a client. The nurse would place the tuning fork at which location first?

On the mastoid process

A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

Heart murmur

A non pregnant female presents to the health care facility and reports the new onset of breast discharge. The nurse assesses the discharge to be milky in appearance without breast tenderness or masses. What additional data should the nurse obtain from this client?

Prescribed medications such as antipsychotic agents

Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds?

Auscultate to determine the heart rate and if the rhythm is normal

The nurse is using the ophthalmoscope to examine the patient's eyes. The nurse holds the scope

in the right hand for the right eye and in the left hand for the left eye

An elderly patient comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment?

Tenting indicates dehydration

The nurse is testing a patient for carpal tunnel syndrome. The patient flexes the wrists at an angle of 90° and holds the backs of the hands to each other for 60 seconds. The patient tells the nurse that he is experiencing a burning pain as a result. Which test is the nurse performing on this patient?

Phalen's

Symptoms of prostate disorder include which of the following?

Incomplete emptying, nocturia, weak urinary stream

A 72-year-old man had hip replacement surgery 2 days ago. The nurse enters the patient's room and encourages him to use the incentive spirometer ten times every hour. What is this action an example of?

Nursing intervention

A nurse examines a client with a paralytic ileus. Which alteration in the bowel sounds should the nurse expect to find with auscultation of the client's abdomen?

Absent

Which of the following factors affect blood pressure?

• Smoking• Age• Stress• Ethnicity• Weight

What are the primary frameworks used in conducting a health assessment?

• Head to toe• Body systems• Functional

Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen?

Flex the client's legs by placing a pillow under the knees

A client states, “My wife died two months ago today.” Which of the following responses would be most appropriate?

“How does that make you feel?”

A 55-year-old bookkeeper comes to the office for a routine visit. The nurse notes that on a previous visit for treatment of contact dermatitis, the client's blood pressure was elevated. She does not have prior elevated readings, and her family history is negative for hypertension. The nurse measures her blood pressure in the office today. Which of the following factors can result in a false high reading?

Blood pressure cuff is tightly fitted.

Why is it important for the nurse to ask the patient what he or she thinks has caused a skin condition?

The patient's perception affects the approach and effectiveness in treating the skin condition

Which of the following is the most sensitive method for detecting hearing loss?

Audiometric testing

A nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate?

Ask the client to remove the glasses before testing.

The nurse is taking routine vital signs toward the end of shift. A patient's BP reads 204/148. His baseline BP has been in the 130s systolic. What should the nurse do first?

Retake the blood pressure

The nurse is assessing a 30-year-old woman who has come to the clinic for treatment of her recent vaginal soreness and pruritis, which have been accompanied by a white, curdy discharge that is not significantly malodorous. Which of the following assessment questions is most likely to be relevant to the client's diagnosis?

“Have you been taking antibiotics lately for any reason?”

Which of the following statements best conveys the rationale for health promotion in a school setting?

Healthy child development is a critical health determinant because of its implications for lifelong health.

The nurse is assessing a 12-year-old boy and finds the following: sparse growth of pubic hair, beginning penile enlargement, and beginning textural changes on the scrotum. The nurse would document which Tanner stage?

2

During a health history, a male client tells the nurse that he "can't breathe well" at night when he is lying down and has trouble sleeping because he wakes up with trouble breathing. The nurse would assess this client further for which of the following?

Heart failure

Which of the following client situations would the nurse interpret as requiring an emergency assessment?

A client who took a drug overdose

A 60-year-old client has difficulty hearing high-pitched sounds. The nurse would document this finding as which of the following?

Presbycusis

While completing the cardiovascular system health history, a patient tells the nurse about using four pillows at night to sleep. The nurse will use this information to further assess which area?

Shortness of breath

What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation?

Ensure that contact with the skin is maintained

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII?

Head and face

A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?

Fingers and toes

What should the nurse assess to test the function of the parietal lobe?

tactile sensation

A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines?

“Do you have any visual changes before the headache?”

During a health history, a 48-year-old client states, “I've noticed that I need to hold my newspaper farther away so that I can read it.” Which of the following would the nurse suspect?

Presbyopia

During a Weber test, the client reports lateralization of sound to the good ear. The nurse interprets this as which the following?

There is a sensorineural hearing impairment.

A group of students is reviewing information about the potential opportunities for nurses with advanced assessment skills. The students demonstrate that they understand the information when they identify which of the following as helping to promote this role?

Expansion of health care networks

A nurse has just performed the test for Allis' sign on a newborn; the result is positive. What did the nurse observe while performing this test?

One knee is lower than the other

An older adult client presents with cramping leg pain when walking, which is relieved by rest; cool pale feet; capillary refill in the toes of 4 to 6 seconds; negative Homans' sign bilaterally; no edema; and inability to palpate dorsalis pedis and posterior tibial pulses bilaterally. Which of the following would the nurse suspect?

Arterial insufficiency

When inspecting the anus, to better inspect the anal opening it would be helpful to instruct the client to do which of the following?

Bear down

The nurse auscultates 20 clicks and gurgles over 1 minute when examining a patient's abdomen. How should the nurse document this finding?

Bowel sounds normal

When examining most body regions, nurses usually perform the four basic examination modes in which of the following sequences?

Inspection, percussion, palpation, auscultation

Which skill does the nurse need to obtain subjective data during the initial comprehensive assessment?

Empathy

The nurse is examining the breasts of a woman with Paget disease. Which of the following would the nurse expect to find?

Red, scaly, crusty areas

A nurse is gathering subjective data. Which of the following would the nurse be most likely to assess?

Feelings of happiness

A nurse obtains the blood pressure in a client who is lying down. Which of the following would the nurse expect?

It will be slightly lower than standing readings.

A mother is worried about her 14-year-old daughter's weight. The daughter weighs 80 kg. What can the nurse teach the mother about her daughter's eating habits?

• Educate the family about the poor nutritional value of fast food• Supply only healthy foods in the house• Supply nutritional information to her daughter

Patients who are frequently hospitalized, as well as nurses, are more commonly diagnosed than the general population with what?

Latex allergy

Which of the following conditions consists of a tight prepuce that, once retracted, cannot be returned?

Paraphimosis

A group of students is reviewing information about the frail elderly and functional status. The students demonstrate understanding when they identify which as an instrumental activity of daily living?

Cooking

On examination the nurse asks the client to close his eyes. He cannot close his left eye. The nurse asks him to open his eyes and raise his eyebrows. His right forehead furrows but his left remains flat. The nurse then asks the client to give a big smile. The right corner of his mouth raises but the left side of his mouth remains the same. What type of facial paralysis does he have?

Peripheral CN VII paralysis

When assessing the ears of older adults, it is necessary to remember that physiologic changes take place as people age. What is a physiologic change that takes place in the ear of an older adult?

Tympanic membrane is more opaque

When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe this heart sound? S2 is:

Accentuated

A mother brings her 13-year-old daughter to the clinic to be vaccinated against the human papillomavirus (HPV). Once the girl receives the first dose, the nurse tells the mother to bring her back when?

2 months

A nurse experiences difficulty with palpation of the dorsalis pedis pulse in a client with arterial insufficiency. What is an appropriate action by the nurse based on this finding?

Assess adequacy of blood flow using a Doppler device.

A nurse inspects a child's legs while standing and notices that the knees turn inward. How should this finding be documented in the medical record?

Genu vulgum

During assessment of the inguinal regions for herniating masses, the nurse instructs the standing male client do which of the following?

Bear down.

With further questioning, she can relate that the pain is worse in the neck, shoulders, hands, low back, and knees. She denies swelling in her joints; she states that the pain is worse in the morning; there is no limitation in her range of motion. On physical examination, she has several points on the muscles of the neck, shoulders, and back that are tender to palpation; muscle strength and range of motion are normal. Which of the following is likely the cause of her pain?

Fibromyalgia

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?

Previous injuries to the head and neck

Equipment used for objective data collection involving the eyes includes which of the following?

• Occlusive covers• Ophthalmoscope• Penlight• Snellen chart

During a scheduled visit to his primary care provider, a 54-year-old man relates a news article he recently read that cast doubt on the efficacy of both digital rectal examination (DRE) and prostate-specific antigen (PSA) testing. How can the clinician best respond?

“Both DRE and the PSA test have roles in the detection of prostate cancer, but neither detects all, or close to all, cases of prostate cancer.”

During a class, a student asks the instructor, “What does the anal canal contain?” Which of the following would the instructor include in the response?

Somatic sensory nerves

When evaluating the jugular venous pressure in a patient with known coronary artery disease, the nurse explains to the patient that the JVP measures the pressure in the

right atrium

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. The nurse interprets this as which of the following?

Positive Rovsing's sign

A nurse observes a client's gait and notes it to be wide-based and staggering. The Romberg test results were positive. The nurse recognizes this as what type of abnormal gait?

Cerebellar ataxia

During the eye assessment, a nurse performs part of the neurological examination for which cranial nerve?

VII

A 57-year-old maintenance worker comes to the office for evaluation of pain in his legs. He is a two-pack per day smoker since the age of 16, but he is otherwise healthy. The nurse is concerned that the client may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system?

Intermittent claudication

Prior to a patient interview, the nurse collects information from the patient's medical record, such as prior surgeries, home medications, allergies, and past treatments. What phase of the interview process is this?

Preinteraction

What instruction should a nurse give a client who is having trouble relaxing with the testing of the patellar deep tendon reflex?

"Place your hands together, lock the fingers, and squeeze"

A nurse is preparing to assess the skin of a client. The nurse performs the following steps. Place these steps in the sequence that the nurse would perform them, from first to last.

nspect skin color and temperature.Inspect for skin lesions.Palpate the skin for texture and moistness.Inspect the scalp and hair.Note the condition of the nail beds.Check capillary refill.

A nurse inspects the gums and teeth of a middle aged adult and notices the presence of small brown spots on the chewing surfaces of several of the molar teeth. What question should the nurse ask the client to determine the cause of this finding?

"Are you experiencing any tooth pain?"

What would the nurse expect to hear when auscultating the lungs of a client who is dehydrated?

Friction rub

An avid swimmer presents with ear pain. Her history includes pain and drainage from the left ear. On examination, she has pain when the ear, including the tragus, is manipulated. The canal is narrowed and erythematous with some white debris in the canal. The rest of the examination is normal. What diagnosis would be most appropriate for this client?

External otitis

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?

She can see at 20 feet what a normal person could see at 100 feet.

The student nurse examines a 62-year-old patient and reports to the preceptor that the patient appears to have an infection in an untreated laceration on the calf. The student is unsure of the assessment because the patient does not have a fever. The preceptor correctly explains that the older adult often does not have a fever with an infection.

True

What physical assessment technique should a nurse use to obtain a pulse on a client?

Light palpation

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